Cultural Competency with Religious, Ethnic, and LGBTQ+ Considerations Nursing CE Course

2.0 ANCC Contact Hours AACN Category B

Syllabus

Upon completion of this activity, participants should be able to:

  • Discuss current cultural issues and access to healthcare in the United States
  • Describe the importance of providing culturally competent care to diverse populations
  • List various national practice guidelines for cultural competency

Introduction

The increasing diversity of the United States brings opportunities and challenges for health care providers, health care systems, and policy makers to create and implement culturally competent healthcare services. From age, gender, race and ethnicity to social class, language, spiritual beliefs, and mental and physical abilities, the range and depth of differences found in the population are many. Cultural competency promotes good communication between health care providers often times and as result of their differences. Failure to acknowledge and address these differences has the opposite effect. National practice guidelines for culturally competent healthcare come from various national organizations.

Upon completion of this module you will be able to discuss current cultural issues in healthcare, describe the importance of providing culturally competent nursing care to diverse populations, and will be able to list national practice guidelines for cultural competence in nursing.


Current Cultural Issues and Trends in the United States

Culture can be defined by group membership, such as racial, ethnic, linguistic or geographical groups, or as a collection of beliefs, values, customs, ways of thinking, communicating, and behaving specific to a group”(Centers for Disease Control and Prevention, 2016) Culture can also refer to other characteristics such as age, gender, sexual orientation, disability, religion, income level, education, or profession (U.S. Department of Health and Human Services, [HHS], 2016).

Cultural competence is the ability to interact effectively with people of different cultures, and as a result, ensures the needs of all community members are addressed (HHS, 2016).

Although the nation is becoming more ethnically and culturally diverse, the workforce of registered nurses (RNs) has not caught up to the trend. Professional organizations have provided suggestions as well as guidelines in assuring that all nurses have an understanding of the patient’s culture. Culturally competent nursing care contributes to a reduction of healthcare disparities through patient empowerment and integration of cultural beliefs and practices for patients in vulnerable groups (Minority Nurses Association, 2019).


Breakdown of the US Population

Race and Ethnicity

The US is a multi-racial and multi-ethnic country. The US officially categorizes its population into six groups: White, African American, Native American/Alaskan Native, Pacific Islander, Asian, and Native Hawaiian. From those groups, Americans identity with ethnic groups that are even more specific. More Americans specify as German than any other ethnicity. Non-Hispanic whites remain the largest group of Americans, followed by Hispanics and blacks or African-Americans. According to the United States Census Bureau (USCB) 2017, the number of racial and ethnic minorities grew from 2015 to 2016, while non-Hispanic whites fell. The fastest growing segments of the population are Asian and mixed race couples (USCB, 2017). Diverse ethnic groups are at a higher risk for chronic illnesses, have shorter life expectancies, and are less likely to receive vital preventative healthcare screenings (Agency for Healthcare Research and Quality, 2015). Individuals may have certain beliefs about their health and care, which is tied to their ethnic background.

The National Institute on Aging (2015) found that Alzheimer's disease is more prevalent among African Americans and Hispanics than other ethnic groups in the U.S. In addition, they found that low socioeconomic status is associated with poorer health and reduced lifespan in the U.S. There are also observed gender differences in health and longevity. For example, overall women live longer than men, but are more likely to develop osteoporosis or depressive symptoms or to report functional limitations as they age; men, on the other hand, are more likely to develop heart disease, cancer, or diabetes.

Hispanics are the largest minority group in the US at 18.10% (USCB, 2017).  Take a look at few of the health beliefs of the most common groups included in the population study.

Table 1: Health Beliefs of Various Groups in the US*

RaceHealth Beliefs
White non-HispanicWestern beliefs may be that disease is an external force, such as a virus or bacteria, or a slow degeneration of the functional ability of the body. Disease is either physical or mental. Whites may view health according to their European cultural background.
HispanicTrust and interpersonal communication may be important. Some may believe strongly in religious, herbal remedies, and healers.
AsianHealth may be seen as a state of balance between the physical, social, and super-natural environment.
Black onlyOlder African Americans may be suspicious of clinicians, because of experiences of past generations of African Americans with health care.

*Overall, these assessments are broad generalizations, and do not represent each ethnicity as a whole. See below for certain religious considerations, and take care to foster an open, communicative relationship with patients.
(McFarland & Wehbe-ALamah, 2018)

Figure 1: US Population by Race


RN Population by Race

About a quarter of the US population of RNs identify as a minority. The Pacific region has the highest percentage of minority nurses, with 30.5% of nurses identifying themselves as belonging to a minority. Black or African American nurses are the highest group at 9.9%. Take a look at the chart below for a breakdown of RNs by race. There is a mismatch between the racial diversity of the US population in relation to the largest group of RNs who are White non-Hispanic. What is needed is more education and training at the student level in order to ensure that teaching opportunities are addressed early (Minority Nurses Association, 2016).

Although efforts to increase diversity (gender, racial, ethnic, and age) have made small gains, nursing faculty diversity levels don't resemble diversity levels of students and communities (Minority Nurses Association, 2016).

Within baccalaureate nursing programs, about 32% of students are from non-White minority groups.

Figure 2: RN Population by Race(Smith, 2018)


Age of the US Population

The largest segment of the US population is those less than 18 years old (USCB, 2017). The number of Americans ages 65 and older is projected to more than double from 46 million currently; to over 98 million by 2060, and the 65-and-older age group’s share of the total population will rise to nearly 24% from 15%. The older population is becoming more racially and ethnically diverse. Between 2014 and 2060 the share of the older population that is non-Hispanic white is estimated to decline by 24 percentage points, from 78.3 % to 54.6% (Population Reference Bureau, 2016).

Americans are living longer and thus; the growth in the number of older adults has been increasing rapidly. Aging adults face more chronic diseases and require more health care for such diseases as:

  • Heart Disease
  • Cancer
  • Stroke
  • Diabetes
  • Alzheimer's disease
  • Chronic bronchitis or emphysema

(Office of Disease Prevention and Health Promotion [ODPHP], 2018)

The Patient Protection and Affordable Care Act (ACA) of 2010 included provisions that added certain preventive services to Medicare, including cancer screenings and immunizations. These services were set in place to prevent disease or help to detect disease early, when treatment is more effective. Unfortunately older adults, especially those from certain racial and ethnic groups, underuse these services. (ODPHP, 2018)


Figure 3: Age of US Population


Sexual Orientation

In the US, current research (Gallop’s Daily Tracking, 2017) found that the percent of the population that identifies lesbian, gay, bisexual, or transgender (LGBT) is increasing and is at 4.5%. LGBT individuals face health disparities linked to societal stigma, discrimination, and denial of their civil and human rights. Discrimination against LGBT persons is associated with high rates of psychiatric disorders, substance abuse, and suicide. Experiences of violence and victimization are frequent for LGBT individuals, and have long-lasting effects on the individual and the community. Personal, family, and social acceptance of sexual orientation and gender identity affects the mental health and personal safety of LGBT individuals (ODPHP, 2018). Findings show that being younger and having lower income is associated with higher rates of being LGBT. In addition, LBGT orientation is increasing in all racial groups. Hispanics have the highest rate at 6.1% followed by Asians at 5%. This study consisted of 340,000 self-reporting interviews and its results are summarized in Chart 4 (Gallop’s Daily Tracking, 2017).

LGBT health disparities, include:

  • 2 to 3 times more likely to attempt suicide.
  • Youth are more likely to be homeless.
  • Lesbians are less likely to get preventive services for cancer.
  • Gay men are at higher risk of HIV and other STDs, especially among communities of color.
  • Lesbians and bisexual females are more likely to be overweight or obese.
  • Transgender individuals have a high prevalence of HIV/STDs, victimization, mental health issues and suicide and are less likely to have health insurance than heterosexual or other LGBT individuals. 
  • Elderly LGBT individuals face additional barriers to health because of isolation and a lack of social services and culturally competent providers.LGBT populations have the highest rates of tobacco, alcohol, and other drug use

Figure 4: %LGBT+ Identifying Population by Race

(ODPHP, 2018)


Disability

In the US, 12.6% of the population is disabled. The most common types of reported disability are walking and independent living. Most people who are disabled are over the age of 65 years old. The USCB (2017) found that 92% of those disabled are over 65 years old while only 8.2% of those who are disabled are younger than 65 years old. The USCB (2015),found that the racial group least likely to report a disability are Asians. Alaskan Natives and American Indians are the mostly likely to report a disability.  Chart 5 lists the findings of this report (USCB, 2015, 2017).

Overall, people with disabilities report seeking more health care than people without disabilities and have greater unmet needs. Health promotion and prevention activities seldom target people with disabilities. For example women with disabilities receive less screening for breast and cervical cancer than women without disabilities. People with intellectual impairments and diabetes are less likely to have their weight checked. Adolescents and adults with disabilities are more likely to be excluded from sex education programs.

Figure 5: Likelihood to Report Disability by Race

(WHO, 2019)

Major Religions in the United States

A study by American Family Survey, (2017) found Americans are increasingly becoming a nation of “none” when it comes to religion. Thirty-four percent of Americans surveyed said they were atheist, agnostic, or “nothing in particular”. Most people who claim to identify as a religion in the US are Christians, and identify as Protestant, Roman Catholic, or Eastern Orthodox. These results are not all-inclusive of all world religions and are estimates. Some percentages are too small and were not included in the results (Religion News, 2017).

Some patients may turn to their religious beliefs to assist them in making medical decisions. When seeking medical treatment they may use their beliefs to guide them on their healthcare arrangements, which can include their modesty, what type of physician they seek out, diet, schedule of treatments and more. (McFarland & Wehbe-Alamah, 2018).

Many patients turn to their beliefs and faith during challenging times. It is important that nurses offer the opportunity for patient’s to discuss their cultural and religious beliefs, so that treatments can be adjusted if needed. Healthcare organizations should invest in providing education for their staff regarding different religions of the world. Through training and exposure, misconceptions will be corrected and a sense of awareness will be fostered in the providers. Education will promote valuable conversations about religion with patients and what exactly that means for their individualized treatment. (McFarland & Wehbe-Alamah, 2018).

Spirituality or religion can be incorporated into healthcare as long as healthcare providers open the channels of communication with their patients. Listening to their beliefs and views on their faith along with how those beliefs are tied into their health can build trust between physician and patient. Being vigilant regarding spiritual/religious beliefs and practices can lead to earlier patient release dates, fewer medical errors and stronger communication between patient and provider. (McFarland & Wehbe-Alamah, 2018).

Figure 6: Major Religions in the US



Health Insurance Coverage

In 2017, 8.8 % of people, or 28.5 million, did not have health insurance at any point during the year (USBC, 2017). The rate of uninsured increased by 3% from 2016- 2017. That increase in the percentage began in the first quarter of Donald Trump’s presidency. In the fourth quarter of 2016, the percentage of uninsured adults in the United States was 10.9 % a low after three years of declines following the passage of the ACA (better known as Obamacare). In 2013, before the law went into effect, nearly 1 in 5 adults lacked insurance. In 2017, that figure rose again to 12.2 percent (The Washington Post, 2018). Working-age adults (age 19-64) make up a much larger share of the uninsured population than any other age group. By contrast, just 1.4% of the uninsured are age 65 and over (USCB, 2017).

Hispanics have the highest rate of being uninsured while non-Hispanic whites have the lowest (USCB, 2017). Take a look at the chart below for race and health insurance coverage.

Figure 7: Health Insurance Coverage by Race in the US



Providing Culturally Competent Care to Diverse Populations

Health care providers must respond to changing patient demographics to provide culturally sensitive care. The development of cultural competence in  nursing practice first requires nurses to have an awareness of the fact that many belief systems exist. Nurses spend the most amount of time with patients and families and should understand various cultural differences when providing care. Understanding cultural differences promotes the nurse-patient therapeutic relationship. Madeleine Leininger's Culture Care Theory is an established nursing theory that emphasizes culture and care as essential concepts in nursing. In addition nursing organizations such as the  American Nurses Association (ANA), provide suggestions for ways to promote cultural competency. Take a look at Leininger’s theory and other suggestions below.

Madeleine Leininger’s Cultural Care Theory

In the mid 1950’s Dr. Madeleine Leininger became a leader in establishing transcultural nursing as an area of study and practice. In 1974-75, under the leadership of Dr. Leininger, nurses and other professionals committed to research, education and practice in this new field founded the Transcultural Nursing Society, originally at the University of Utah. According to the transcultural nursing society (2019), “The goal of practice is to promote health and well-being of individuals and populations by reducing health and care disparities through culturally congruent and competent approaches at the multilevel contexts of care.” Madeleine Leininger's Culture Care Theory is an established nursing theory that provides meaningful nursing care services to people according to their cultural values and health-illness context. Her model emphasizes culture and care as essential concepts in nursing. Leininger’s model has been developed into a subfield of nursing called “Transcultural Nursing” (McFarland & Wehbe-Alamah, 2018).

Transcultural nursing is defined as a learned subfield or branch of nursing which focuses upon the comparative study and analysis of cultures with respect to nursing and health-illness caring practices, beliefs, and values with the goal  to provide meaningful and efficacious nursing care services to people according to their cultural values and health-illness context. Through the help of Leininger’s theory, nurses can observe how a patient’s cultural background is related to their health, and use that knowledge to create a nursing plan that will help the patient get healthy quickly while still being sensitive to various cultural backgrounds (McFarland & Wehbe-Alamah, 2018).

Assessment concepts in Leininger’s Theory of Culture Care and Universality includes:

  • Age
  • Communication and language
  • Dress
  • Use of space
  • Gender considerations
  • Sexual orientation
  • Ability/Disability
  • Occupation
  • Socioeconomic status
  • Interpersonal relationships
  • Appearance
  • Foods and meal preparation-related life ways


Three Modes of Nursing Care Decisions and Actions

In the planning and implementation stage, care decisions and actions include three modes: care preservation or maintenance, cultural care accommodation or negotiation and cultural care repatterning or restructuring. It is here that nursing care is delivered.

  1. Cultural care preservation or maintenance
    • Cultural care preservation is also known as maintenance and includes those assistive, supporting, facilitative, or enabling professional actions and decisions that help people of a particular culture to retain and/or preserve relevant care values so that they can maintain their well-being, recover from illness, or face handicaps and/or death.

  2. Cultural care accommodation or negotiation
    • Cultural care accommodation also known as negotiation, includes those assistive, supportive, facilitative, or enabling creative professional actions and decisions that help people of a designated culture to adapt to or negotiate with others for a beneficial or satisfying health outcome with professional care providers.

  3. Culture care repatterning or restructuring
    • Culture care repatterning or restructuring includes those assistive, supporting, facilitative, or enabling professional actions and decisions that help a clients reorder, change, or greatly modify their lifeways for new, different, and beneficial health care pattern while respecting the clients cultural values and beliefs and still providing a beneficial or healthier lifeway than before the changes were coestablished with the clients (Mc Farland et al, 2018).


Figure 8: Barriers to/Support for Cultural Competency

(McFarland & Webhe-Alamah, 2018)


National Guidelines for Cultural Competency

There are various organizations that provide guidance for nurses and other healthcare providers on providing cultural competent care. The two discussed here are from the ANA and the US HHS.

The ANA lists competencies that the registered nurse should possess in order to provide culturally congruent care.  Some of the key points are summarized (Table 9) and fall into 3 basic categories beginning with self-assessment, patient identification and respect and finally advocating, promoting and educating. For more information about each stage, see the chart that follows (Marion et al., 2017).

Figure 9: ANA's Culturally Congruent Practice

(Marion et al., 2017)


Case Study: Application of Leininger's Theory

Patient scenario:

Luz is a 27-year-old Hispanic female patient who has entered the government-subsidized women’s clinic. She is from Mexico and only speaks Spanish. You are to be her clinic nurse, but you don’t speak Spanish. You ask another nurse you know who is a native Spanish speaker and understands English well to translate. The following is the translated dialogue between Luz and you.


You: “What bring you into the clinic today Luz?”

Luz: “I’m worried I may be pregnant, and I want to know if you can give me a free pregnancy test so I don’t have to pay for one.”

You: “Yes, we can surely do that. Before I do that I’d like to ask you a few questions is, that ok?”


Before proceeding with your assessment you should do the following:

  • Self Assessment: What are my beliefs, values and cultural heritage
  • Patient cultural assessment: What are some of the beliefs about health care from Hispanic people? Will she have differences and if so assess for those.
  • Considerations: Hispanic people may have strong ties to family and religion.
  • Trust: I must gain trust and this can occur by understanding her cultural values and beliefs

Using Leininger’s Theory, you assess and have the following information:

  • Age: 27
  • Communication and language: Spanish only
  • Dress: Clothes and shoes are dirty
  • Use of space: Sits with arms crossed
  • Gender considerations: Hispanic culture is a paternalistic
  • Sexual orientation: Straight
  • Ability and disability: No apparent disabilities
  • Occupation: Maid in a hotel, undocumented
  • Socioeconomic status: Poverty line
  • Interpersonal relationships: Has 2 brothers and a sister living with her
  • Appearance: Tired, poor hygiene
  • Foods and meal preparation-related life ways: Meals prepared with siblings


Apply the 3 modes of nursing care decisions and actions

Cultural care preservation or maintenance:

Luz’s pregnancy test is positive and it appears from the assessment she is 8 weeks along. She doesn’t want to keep the baby because of her economic status. She explains that she would consider adoption because she is a Catholic and doesn’t believe in abortion. As her nurse, you respect her culture and decision and provide her with information in Spanish regarding adoption resources.

Cultural care accommodation or negotiation:

In addition, you connect her with a clinic in another location for her future visits where the majority of the staff speaks Spanish. She is grateful and you can sense you have promoted a trusting therapeutic relationship.

Culture care repatterning or restructuring:

Since Luz states this pregnancy was unintended you ask her how she plans to prevent this from happening again. She states that although she doesn’t believe in birth control due to her religion she thinks that if she had money to buy condoms she would make sure they were used in the future. You agree to provide her with some of the free condoms at the clinic and provide her with more information on natural birth control methods in Spanish.


The scenario has provided Luz with culturally sensitive care by assessing her back ground and beliefs and thus helped her to maintain and attain the healthcare she was seeking while helping her to prevent unwanted pregnancies in the future (Marion et al, 2017).  


CLAS Standards

The National CLAS Standards (CLAS) were developed by the Office for Minority Health (OMH) at the U.S. Department of Health and Human Services (HHS). They call on health providers and health care organizations to provide effective, equitable, understandable, and respectful quality care and services. These services should be also implemented at every point of contact within an organization, from admission to discharge and should be implemented through every touch point including billing and follow up surveys.

The CLAS Standards suggest ways to promote communication which include:

  • Cross cultural communication skills: Understand differences, don’t make assumptions, and avoid jargon.
  • Verbal communication skills: Assess language usage and seek adequate translation when appropriate.
  • Written communication skills: Use written materal in the preferred language when available.
  • Language Assistance services: Individuals should be made aware that language assistance services are available at an organization.

The following is a graphic representation of the 4 concepts, which include effective, equitable, respectful and understandable care. Following the chart is a brief description (Table 3) of each type of care (HHS, 2017).

Figure 10: National Standards for Communication, Language and Assistive Services (CLAS)

CLAS Types of Care and Examples
Effective CareThese services help restore an individual’s health to their desired health status while protecting future health. Health care providers should assess and plan and negotiate the plan of care with each individual.
Equitable CareThese services apply to all groups regardless of their cultural identify or identities. The goal is to reduce the burden of illness, injury and disability to improve the health and functioning of all people of the US.
Respectful CareThese services promote an environment where individuals from diverse backgrounds and health care beliefs will feel comfortable discussing their needs with any member of the healthcare team.
Understandable CareThese services rely on a clear exchange of information between those who provide and receive care. Individuals should be able to fully comprehend how to access services, understand what their treatment options are and how to become and remain well. Providing understandable services also includes being aware of and providing health education in accordance with  literacy levels, preferred languages, and other communication needs.

(HHS, 2017)

References

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Bump, P. (2018, January 16). The Washington Post. Three-two million more people were uninsured at the end of 2017 than at the end of 2016. Retrieved from: https://www.washingtonpost.com/news/politics/wp/2018/01/16/3-2-million-more-people-were-uninsured-at-the-end-of-2017-than-at-the-end-of-2016/?utm_term=.aa08c71f4c3a.

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Gallop. In the U.S., Estimate of LGBT Population Rises to 4.5%. Retrieved  from: https://news.gallop.com/poll/234836/estimate-lgbt-population-rises.aspx. 

Marion, L., Douglas, M., Lavin, M., Barr, N., Gazaway, S., Thomas, L. Bickford, C.,  (2016, November) “Implementing the New ANA Standard 8: Culturally Congruent Practice” OJIN: The Online Journal of Issues in Nursing 22(1). doi: 10.3912/OJIN.Vol22No01PPT20.

McFarland, M. & Wehbe-Almah, H. (2018). Leininger’s Transcultural Nursing. (4th ed.) Special Topics in Transcultural Nursing using the Culture Care Theory. (197-215). New York: McGraw Hill Education.

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 National Institute on Aging. Goal F: Understand health disparities and develop strategies to improve the health status of older adults in diverse populations. Retrieved from https://www.nia.nih.gov/about/aging-well-21st-century-strategic-directions-research-aging/goal-f-understand-health.

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Religion News. Religious “nones” are gaining ground in American and are worried about the economy. Retrieved from https://religionnews.com/2017/11/16/religious-nones-are-gaining-ground-in-america-and-theyre-worried-about-the-economy-says-new-study/.

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US Department of Health and Human Service of Minority Health. New CLAS Tool Kit from OMH. Retrieved from https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=1&lvlid=6.

World Health Organization. Disability and Health. Retrieved from https://www.who.int/news-room/fact-sheets/detail/disability-and-health.